Healthcare Provider Details

I. General information

NPI: 1154356624
Provider Name (Legal Business Name): IDAHO SPORTS MEDICINE INSTITUTE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 UNIVERSITY DR
BOISE ID
83706-3009
US

IV. Provider business mailing address

1188 UNIVERSITY DR
BOISE ID
83706-3009
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-8250
  • Fax: 208-345-9514
Mailing address:
  • Phone: 208-336-8250
  • Fax: 208-345-9514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberN/A FOR GROUP
License Number State

VIII. Authorized Official

Name: JENNIFER R. MILLIER
Title or Position: OWNER/PARTNER
Credential: M.D.
Phone: 208-336-8250